PM Vishwakarma
(Registration Form)
Personal Details
Full Name Father/Spouse Name Date Of Birth
Karulal Surywanshi Kishnlal Suraywashi 01-01-1984
Marital Status Gender Category
Married Male SC
Divyangjan Business in same state?
No Yes
Business in same district? Minority?
No No
Contact Details
Mobile No. Aadhaar No. PAN Card
8959370460 XXXXXXXX8761 N.A.
Family Details
Ration Card No.
28405993
Name Relationship Aadhaar No.
Chandari Bai SELF xxxxxxxxxxxx
Aadhaar Address
Aadhaar Address
C/o: S/O: Kishnlal Suraywashi Loc: SITAMAU vtc: Manpura Subdist: Sitamau Street: ISHAKPUR State: Madhya Pradesh po: Manpura pc: 458389 dist: Mandsaur Country: India
State District Pin code
MADHYA PRADESH Mandsaur 458389
Do you Come under Gram Panchayat?
Yes
Block Gram Panchayat
SITAMAU RAJNAGAR
Current Address
Current Address
C/o: S/O: Kishnlal Suraywashi Loc: SITAMAU vtc: Manpura Subdist: Sitamau Street: ISHAKPUR State: Madhya Pradesh po: Manpura pc: 458389 dist: Mandsaur Country: India
State District Pin code
MADHYA PRADESH Mandsaur 458389
Do you Come under Gram Panchayat?
Yes
Block Gram Panchayat
N.A. N.A.
Profession/ Trade Details
Profession / Trade Name
Sub Category
Cobbler (Charmakar)/Shoesmith/ Footwear Artisan
Business Address
C/o: S/O: Kishnlal Suraywashi Loc: SITAMAU vtc: Manpura Subdist: Sitamau Street: ISHAKPUR State: Madhya Pradesh po: Manpura pc: 458389 dist: Mandsaur Country: India
Business State Business District
MADHYA PRADESH Mandsaur
Saving Bank Details
Name of Bank IFSC Code Name of Branch
HDFC BANK LTD hdfc0000470 Mandsaur - Madhya Pradesh
Account No. Confirm Account No.
XXXXXXXXXXXXXX4002 50100690534002
Credit Support
Do you want Credit Support? Loan Amount Required (1st Tranche) Preferred Bank to Take Loan
Yes 100000 HDFC BANK LTD
Preferred Branch to Take Loan Loan Purpose Purchase of Equipments
Mandsaur - Madhya Pradesh Yes Yes
Working Capital / Operating Expanses Business Expansion Outstanding Amount (in Rs.)
Yes Yes N.A.
Existing Loan Monthly EMI Amount (in Rs.) Total Monthly Family Income (in Rs.)
N.A. N.A. N.A.
Digital Incentive Details
Are you Digitally Active? UPI ID UPI ID Linked Mobile Number
No N.A. N.A.
Skill Training
You are eligible for skill training for below training programes.
Basic (5 Days) Skill Training
Advance (15 Days) Skill Training
Tool Kit
Once you are registered and skill training certified you will be given a grant of ₹15,000
Marketing Support
Marketing Support question that applies to your business expansion
Declaration Details
Declaration and Authorization
1. I hereby declare that I am engaged in the trade as indicated in the application form.
2. I hereby declare that apart from myself, no other member of my family has registered for PM Vishwakarma and that no member of my family is in government
service.
3. I have no objection to authenticate my Aadhaar number, share the same with other Ministries / Departments under the Government of India or the State
Government for the purpose of extension of benefits under any of their Schemes, carry out e-KYC and accessing my credit history & credit score from credit
bureau by the lenders and their authorized agents. The consent and purpose of collecting Aadhaar has been explained to me in local language.
MoMSME/Lending Institution has informed me that my Aadhaar submitted herewith shall not be used for any purpose other than mentioned above, or as per
requirements of law. I have been informed that this consent and my Aadhaar will be stored along with my account details with MoMSME or their authorised
agent as per the extant law.
4. I hereby give my consent for sharing of data including but not limited to details of my PAN Card, Aadhaar, GST, Bank Details, mobile number and other
ancillary data with persons as defined in Digital Personal Data Protection Act, 2023 to avail benefits of PM Vishwakarma Scheme including Recognition,
Skill Upgradation, Toolkit Incentive, Credit Support, Incentive for Digital Transaction and Marketing Support.
5. I hereby agree that my application may also be processed for availing Udyam Assist Certification which will enable me for Priority Sector Lending (PSL)
benefits.
6. I hereby declare that information given above is true to the best of my knowledge. I am well aware of the fact that, if the information given by me is proved
false/not true, I will be liable for action as per the law. Also, all benefits shall be summarily withdrawn.
Date : 22/06/2025 Signature of Applicant(s)
Place : Mandsaur
